prevention and screening
TRANSCRIPT
PREVENTION AND SCREENING:
WOMEN’S HEALTH GUIDELINES UPDATEALEECE FOSNIGHT, MSPAS, PA-C, CSC-S, CSE, NCMP, IF
UROLOGY, WOMEN’S HEALTH, SEXUAL MEDICINE
SKIN, BONES, HEARTS, AND PRIVATE PARTS 2021
WELL WOMAN VISIT
WELL WOMAN VISIT – WHAT SHOULD BE INCLUDED?
History
Reason for visit
Heath status – medical, surgical, family
Dietary and nutrition assessment
Physical activity
Use of CAM
Tobacco, alcohol, recreational drug use
Abuse/neglect
Sexual practices
Physical exam
Height
Weight
BMI
Waist circumference
BP and HR
Evaluation and Counseling
Exercise and dietary assessment
Psychosocial Evaluation
Interpersonal/family/friend relationship
Cardiovascular Risk Factors
Family history
HTN, HLD, DM
Immunizations
DPT or Tdap booster
Varicella Vaccine
Influenza Vaccine
Should happen at least
once a year.
BODY IMAGE
Are there any screening guidelines?
ACOG and AAP recommendations
Healthy At Every Size, HAES®
Body dysmorphia and disordered eating
Women vs Men
Half of all girls by age 6
Consider a social media diet
Influences by culture
Eating disorders and mental health
Be Body Positive Model
1. Reclaim health
2. Practice intuitive self-care
3. Cultivate self-love
4. Declare your own authentic beauty
5. Build community
WELL WOMAN VISIT – WHAT SHOULD BE INCLUDED?
History
Reason for visit
Heath status – medical, surgical, family
Dietary and nutrition assessment
Physical activity
Use of CAM
Tobacco, alcohol, recreational drug use
Abuse/neglect
Sexual practices
Physical exam
Height
Weight
BMI
Waist circumference
BP and HR
Evaluation and Counseling
Exercise and dietary assessment
Psychosocial Evaluation
Interpersonal/family/friend relationship
Cardiovascular Risk Factors
Family history
HTN, HLD, DM
Immunizations
DPT or Tdap booster
Varicella Vaccine
Influenza Vaccine
Should happen at least
once a year.
WELL WOMAN VISIT SPECIFICS
Ages 13-18
School, safety, relationships, contraception, suicide
Ages 19-39
Reproduction, perimenopause, increased risk factors, IPV
Ages 40-64
Perimenopause, menopause, mammography, colonoscopy, osteoporosis
Ages >65
Menopause and risk factors
CERVICAL CANCER SCREENING
New Guidelines April 2020
Based on risk strategy – risk tables to guide practice
Routine screening applies only to asymptomatic individuals who do not require surveillance for prior abnormal screening results
New Guidelines
Recommendations (colposcopy and treatment vs surveillance) are based on risk for CIN 3+
Risk determined by prior history as well as screen results
Risk tables also address ‘unknown history’ scenario
Deferral of colposcopy: Low risk for CIN 3+ (risk defined by tables)
Repeat HPV testing or cotesting at 1 year
At the 1-year follow-up test, referral to colposcopy if still abnormal
Expansion of expedited treatment category (biopsy not needed prior to therapy), for example, in nonpregnant patients ≥25 years, expedited treatment is
Preferred: CIN 3+ risk is ≥60%
Preferred: HPV 16–positive HSIL cytology and never or rarely screened patients with HPV-positive HSIL regardless of HPV genotype
Acceptable: CIN 3+ risk is between 25% and 60%
Shared decision making is important in the context of “impact on pregnancy outcomes”
Excisional treatment
Preferred over ablation for HSIL (CIN 2 or CIN 3) in the US
Recommended for AIS
CIN 1
Observation is preferred vs treatment
Treatment acceptable with persistent CIN 1 results >2 years
Lower Anogenital Squamous Terminology (LAST)/World Health Organization (WHO) recommendations for reporting histologic HSIL
Include HSIL (CIN 2) and HSIL (CIN 3) (i.e., include CIN 2 and 3 qualifiers)
Reflex cytology
Should be performed on all positive HPV tests, regardless of genotype
If HPV 16 and 18 testing is positive but additional laboratory testing of the same sample is not feasible, proceed directly to colposcopy
Surveillance recommendations following histologic HSIL, CIN 2, CIN 3, or AIS
Continue surveillance with HPV testing or cotesting at 3-year intervals for at least 25 years (recommended)
>25 years is acceptable “for as long as the patient’s life expectancy and ability to be screened are not significantly compromised by serious health issues”
HPV assays
The ASCCP consensus document states the following in reference to HPV tests
CERVICAL CANCER SCREENING
American Cancer Society American College of Obstetricians
and Gynecologists
U.S. Preventative Services
Task Force
Ages 25-64
• Primary hrHPV testing only every 5
years
OR
• hrHPV and cytology every 5 years
25-64 years
• Cytology alone every 3 years
Ages >65
• Stop if normal testing and no history
of CIN2+
Ages 21-29
• Cytology alone every 3 years
Ages 30-64
• Preferred = CoTest (hrHPV and
cytology) every 5 years
• Acceptable = Cytology alone every 3
years
• Can be considered = hrHPV
screening alone no more frequently
than every 3 years
Ages >65
• Stop if normal testing and no history
of CIN2+
Ages 21-29
• Cytology alone every 3 years
Ages 30-64
• Cytology alone every 3 years
• hrHPV testing only every 5 years
• CoTest (hrHPV and cytology) every
5 years
Ages >65
• Stop if normal testing and no history
of CIN2+
ASCCP MANAGEMENT GUIDELINES
https://www.asccp.org/management-guidelines
ASCCP MANAGEMENT GUIDELINES
BREAST CANCER SCREENING
American Cancer Society
2015
National Comprehensive
Cancer Network 2019
U.S. Preventative Services
Task Force 2016
American College of
Obstetricians and
Gynecologists 2017
Mammography
Informed decision-making with a
health care provider ages 40-44.
Every year starting at age 45-54.
Every 2 years (or every year if a
woman chooses to do so) starting at
age 55, for as long as a woman is in
good health.
Every year starting at age 40, for as
long as a woman is in good health.
(3D mammography – breast
tomosynthesis – may be considered)
Informed decision-making with a
health care provider ages 40-49.
Every 2 years ages 50-74.
Insufficient evidence in ages >75.
Offer every year starting at age 40.
Initiate at ages 40-49 after
counseling.
Initiate annually no later than age 50
years.
May discontinue at age 75.
Clinical Breast Exam
Not recommended. Every 1-3 years ages 25-39.
Every year starting at age 40.
Not enough evidence to recommend
for or against.
Every 1-3 years ages 25-39.
Every year starting at age 40.
Self Breast Exam
Not recommended Recommends breast awareness. Not enough evidence to recommend
for or against.
Recommends breast awareness.
BREAST CANCER SCREENING – ABUS
Having dense breasts
increases a woman’s
likelihood to develop
cancer four to six times.
EVALUATION OF A BREAST MASS
Discovered by partner or self breast
exam, CBE, or screening mammography
History
How long has mass been there?
Nipple discharge or skin changes?
Trauma or injury to the area?
Medications?
Relationship to menstrual cycle?
Family history of breast disease
Physical exam – if not found by provider
on CBE, a thorough exam and inspection
should be performed
Size, shape, consistency, mobility, location
Diagnostic imaging
Under age 30 – breast US
Over 40 – diagnostic mammography with
breast US as indicated
MRI reserved for high-risk patients
Breast Imaging Reporting and Data
System (BI-RADS) to determine need for
biopsy
Solid masses need biopsy
FNA with/without US guidance
Core needle biopsy
Surgical biopsy
BI-RADS Classification
0: Unsatisfactory assessment –
additional imaging needed
1: Negative findings – routine
follow-up recommended
2: Benign findings – no
malignancy suspected
3: Probably benign lesion – short
term follow-up indicated
4: Suspicious abnormality
5: Highly suggestive of
malignancy
6: Known malignancy
BENIGN BREAST DISEASE
Nonproliferative Breast Lesions (Breast Cancer Risk = 1.27)
Breast cyst (simple) Round, ovoid fluid-filled masses; firm, mobile, well-demarcated; premenopausal women (age 35-50); influenced by hormonal
changes; acute enlargement can cause pain
Complex cyst Thick walls and/or septa >0.5mm on US; anechoic or echogenic; Dx with FNA/core biopsy/surgery
Mild hyperplasia of usual type Increase in number of epithelial cells within a duct; Dx with FNA/core biopsy/surgery
Proliferative Breast Lesions without Atypia (Breast Cancer Risk = 1.88)
Fibroadenoma Mixed fibrous and glandular tissue; aberration of normal breast development; smooth, firm, rubbery, mobile mass; common age
15-35; Dx with core biopsy/surgery
Juvenile fibroadenoma Unilateral, painless, rapidly growing solitary mass >5cm; ages 10-18; Tx with surgical excision
Intraductal papilloma Wart-like growth in lactiferous ducts; small lump near nipple with clear/bloody discharge; ages 35-50; Dx with core biopsy; Tx
observation vs surgical excision
Usual ductal hyperplasia Increase in number of cells in duct without atypia, incidental finding on biopsy
Radial scars AKA complex sclerosing lesion; fibroelastic core with radiating ducts and lobules; incidental finding
Proliferative Breast Lesions with Atypia (Breast Cancer Risk = 4.24)
Atypical hyperplasia Proliferation of dysplastic cells in ducts or lobules; 10% of biopsies; pre-malignant; Dx core biopsy; Tx with surgical excision;
increased screening follow-up; avoid hormones; chemoprevention in select women
INTIMATE PARTNER VIOLENCE
U.S. Preventive Service Task Force (USPSTF) Recommendation:
Screen women of childbearing age for intimate partner violence (IPV), such as domestic violence (DV), and provide or refer women who screen positive to intervention services. This recommendation applies to women who do not have signs or symptoms of abuse.
According to the CDC, roughly 1.5 million women are raped and/or physically assaulted each year in the United States.
Intimate partner violence (IPV) affects as many as 324,000 pregnant women each year.
USPSTF screenings are directed at patients and can be self-administered or used in a clinician interview format.
The 6 tools that showed the most sensitivity and specificity were:
HITS (Hurt, Insult, Threaten, Scream)
OVAT (Ongoing Violence Assessment Tool)
STaT (Slapped, Things and Threaten)
HARK (Humiliation, Afraid, Rape, Kick)
CTQ-SF (Modified Childhood Trauma Questionnaire–Short Form)
WAST (Woman Abuse Screen Tool)
Other screening tools for pregnant women include 4 Ps and the Abuse Assessment Screen. CDC has compiled a comprehensive list of screening instruments that have been tested on various patient populations.
Studies have shown that patient self-administered, or computerized screenings are as effective as clinician interviewing in terms of disclosure, comfort, and time spent screening.
INTIMATE PARTNER VIOLENCE
Barriers
Time constraints
Discomfort with the topic
Fear of offending the patient or partner
Need for privacy
Perceived lack of power to change the problem
A misconception regarding patient population’s risk of exposure to IPV
www.thehotline.org
1-800-799-7233
BONE DENSITY SCREENING
By 2020, approximately 12.3 million individuals in the United States older than 50 years are expected to have osteoporosis.
Osteoporotic fractures, particularly hip fractures, are associated with limitations in ambulation, chronic pain and disability, loss of independence, and decreased quality of life, and 21% to 30% of patients who experience a hip fracture die within 1 year.
The USPSTF recommends screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in women 65 years and older.
The USPSTF recommends screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in postmenopausal women younger than 65 years at increased risk of osteoporosis, as determined by a formal clinical risk assessment tool.
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis to prevent osteoporotic fractures in men.
Endocrine Society recommends for men ages >70 years
ACOG recommends selective screening in postmenopausal women younger than 65 years who have osteoporosis risk factors or an adult fracture
Medications that may
cause bone loss:
Steroid medications
Thyroid hormones
Anti-seizure medicines
Aromatase Inhibitors
Certain cancer medications
Gonadotropic releasing
hormone (GnRH)
Proton Pump Inhibitors
Selective Serotonin
Reuptake Inhibitors (SSRIs)
Thiazolidinediones
Depo-Provera®
BONE DENSITY SCREENING
National Osteoporosis
Foundation 2014
America Association of
Clinial Endocrinologists
(AACE) 2020
U.S. Preventative Services
Task Force 2018
American College of
Obstetricians and
Gynecologists 2018
Women over the age of 65
Men over the age of 70
If you break a bone after age 50
Menopausal age with risk factors
Postmenopausal under age 65 with
risk factors
Men aged 50-69 with risk factors
Clinical Practice Guidelines for the
Diagnosis and Treatment of
Postmenopausal Osteoporosis 2020
All women >65 years of age
Women <65 with risk factors:
Risk factors for falling
Early menopause
Smoking/Alcohol
Height loss kyphosis
Long-term systemic glucocorticoid
therapy
All women >65 years of age
Women at increased risk for
fractures, beginning at age 60
Not enough evidence to support
men being screened unless risk
factors are present.
All women >65 years of age
Women younger than 65 with the
following risk factors:
History of fragility fracture
Body weight less than 127 lbs
Medical causes of bone loss
Parental history of hip fracture
Current smoker
Alcoholism
Rheumatoid arthritis
The FRAX® Tool
www.shef.ac.uk/FRAX
COLON CANCER SCREENING
COLON CANCER SCREENING
People at average risk of colorectal cancer should start regular screening at age 45.
People who are in good health and with a life expectancy of more than 10 years should continue regular colorectal cancer screening through the age of 75.
People ages 76 through 85 should make a decision with their medical provider about whether to be screened, based on their own personal preferences, life expectancy, overall health, and prior screening history.
People over 85 should no longer get colorectal cancer screening.
What are the tests?
Stool-based tests:
Highly sensitive fecal immunochemical test (FIT) every year
Highly sensitive guaiac-based fecal occult blood test (gFOBT) every year
Multi-targeted stool DNA test (MT-sDNA) every 3 years
Visual exams:
Colonoscopy every 10 years
CT colonography (virtual colonoscopy) every 5 years
Flexible sigmoidoscopy (FSIG) every 5 years
DEPRESSION
The USPSTF recommends screening in all adults regardless of risk factors.
Among older adults, risk factors for depression include disability and poor health status related to medical illness, complicated grief, chronic sleep disturbance, loneliness, and a history of depression.
Risk factors for depression during pregnancy and postpartum
poor self-esteem
child-care stress
prenatal anxiety
life stress
decreased social support
single/unpartnered relationship status
history of depression
difficult infant temperament
previous postpartum depression
lower socioeconomic status
unintended pregnancy.
SLEEP
National Sleep Foundation recommends 7-9 hours of sleep per night for an adult
Not current guidelines by ACOG, NAMS, USPSTF
Should we screen for sleep issues and concerns?
Short sleep and disturbed sleep is a causal factor for 20 percent of serious car accidents
Poor sleep is a better predictor of developing DMT2 than lack of physical activity
Inadequate sleep impairs brain functioning
Cognitive and motor functioning
12% greater risk of mortality with fewer than 5-6 hours every night
What is adequate?
42% of your day should be reserved for rest = 10 hours
Hours in a Day
Work/Family Sleep Connection Exercise Food Wild Card
8 hours 14 hours
Nagoski E and Nagoski A. Burnout: The secrete to unlocking the stress cycle. 2019.
SEXUAL HEALTH SCREENING
SEXUAL HEALTH SCREENING
SEXUAL HEALTH SCREENING
HIV SCREENING
An estimated 1.1 million people in the United States have HIV and approximately 1 in 7 (nearly 15%) are unaware of their status
About 40% of new HIV infections are transmitted by people undiagnosed and unaware they have HIV
CDC recommends that EVERYONE between the ages of 13 and 64 get tested for HIV at least once as part of routine health care
For those at higher risk, CDC recommends getting tested at least once a year
Missed opportunities
More than 75% of patients at high risk for HIV who saw a PCP in the last year weren’t offered an HIV test during their visit.
Treatment
PrEP – Pre-Exposure Prophylaxis
PEP – Post-Exposure Prophylaxis
Active HIV/AIDS
Sexism Sexual Violence Taboo, Shame, Stigma
Racism
Heteronormativity Homophobia
Ableism Ageism Sizeism
BARRIERS TO POSITIVITY
CHECK YOUR BIAS!
Harvard and Project Implicit
Implicit Association Test
https://www.projectimplicit.net/
REFERENCES
Dohnt, Hayley K, Tiggemann M. “Body image concerns in young girls: The role f peers and media prior to adolescence.” Journal of Youth and Adolescence 35, no. 2 (2206): 135-145.
Perkins R et al. 2019 ASCCP Risk-Based Management Consensus Guidelines Committee 2019 ASCCP Risk-Based Management Consensus Guidelines for Abnormal Cervical
Cancer Screening Tests and Cancer Precursors, Journal of Lower Genital Tract Disease: April 2020 - Volume 24 - Issue 2 - p 102-131.
Egemen D et al. Risk Estimates Supporting the 2019 ASCCP Risk-Based Management Consensus Guidelines, Journal of Lower Genital Tract Disease: April 2020 - Volume 24 -
Issue 2 - p 132-143.
The utility of and indications for routine pelvic examination. ACOG Committee Opinion No. 754. American College of Obstetricians and Gynecologists. Obstet Gynecol
2018;132:e174–80.
NCCN Guidelines Version 1.2017, Breast Cancer Screening and Diagnosis, 2 June 2017. http://oncolife.com.ua/doc/nccn/Breast_Cancer_Screening_and_Diagnosis.pdf.
Accessed December 3, 2018.
BI-RADS Classification. www.acr.org. Accessed December 3, 2018.
Tice J, Migloioretti D, Li C, et al. Breast density and benign breast disease: risk assessment to identify women at high risk of breast cancer. J Clin Oncol 2015; 33:3137-43.
Guray M, Sahin A. Benign breast diseases: classification, diagnosis, and management. Oncologist 2006; 11:435-49.
Centers for Disease Control, Intimate Partner Violence, https://www.cdc.gov/media/presskits/aahd/violence.pdf
USPSTF Recommendation Statement: Screening for Osteoporosis to Prevent Fractures. JAMA. 2018;319(24):2521-2531.
2018 Updates to Colon Cancer Screening, American Cancer Society, https://www.cancer.org/latest-news/american-cancer-society-updates-colorectal-cancer-screening-
guideline.html, accessed March 30, 2020
Screening for Depression in Adults US Preventive Services Task Force Recommendation Statement. JAMA January 26, 2016 Volume 315, Number 4.
National Coalition for Sexual Health Provider Postcard Questionnaire, https://nationalcoalitionforsexualhealth.org/tools/for-healthcare-providers/body/Provider-
Postcard_ALL_9.25.19.pdf, accessed March 30, 2020.
